One of the most fundamental ways to evaluate the state of the prostate is through the rectum. Digital rectal examination, also known as a prostate exam, is an examination in which your doctor examines your prostate by palpating your rectum. This examination may be uncomfortable, but is not painful and is essential for a comprehensive diagnosis. A prostate tumour will often feel bumpy and hard as a stone and is therefore distinguishable from the smooth surface of an enlarged prostate. If a tumour is suspected during this examination, a prostate biopsy will be suggested.

What is the PSA test?

Prostate-specific antigen (PSA) is clinically the most reliable prostate cancer marker. It is an enzyme produced by both normal and cancerous prostate cells and testing its concentration in the blood is a commonly used method for diagnosing prostate cancer. The abbreviation PSA refers to a protein produced by the glands of the prostate.

As the primary function of the PSA protein is to liquefy semen, its greatest concentration is in the seminal fluid and only a small amount is released into the blood. Every man with a prostate therefore has a certain level of PSA. If the structure of the prostate cells or glands is damaged (ie by a prostate tumour), the PSA is released into the blood in higher amounts. If the PSA level in the blood rises above a certain level (determined by the patient’s age and size of the prostate), it is recommended to perform further prostate examinations such as a prostate biopsy.

Blood tests to determine PSA levels are not only carried out in men with symptoms of prostate cancer (such as difficulty urinating, erection problems or pelvic and back pain, etc.) but also in men without symptoms as a part of preventive screening. A successful cancer treatment almost always depends on early detection of a malignant tumour and accurate diagnosis.

Higher levels of PSA can be linked to prostate cancer, but also to a number of other diseases such as benign prostatic hyperplasia, prostatitis, acute urinary retention or can be present after some urological procedures. Higher PSA also occurs following sexual intercourse. Unfortunately, some types of prostate cancer may have no effect on the PSA level in the blood. Therefore, a digital prostate exam needs to follow.

A higher PSA level in the blood does not necessarily mean prostate cancer. It can also be linked to a number of other health problems or other conditions:

• Feverish urinary tract infections, acute inflammation of the prostate (acute prostatitis).
• A fluctuating, persistently elevated PSA level may indicate chronic inflammation of the prostate (chronic prostatitis), but biopsy is usually required to confirm this diagnosis.
• Following after some invasive examination (cystoscopy, colonoscopy).
• Acute urinary retention, e.g. in benign prostatic hyperplasia.

Prior to blood sampling for PSA test

At least 48 hours before blood collection, physical activities that could affect prostate tissue should be avoided [1], such as:

• Bicycling
• Horse riding
• Prostate massage, sex, ejaculation

Before the collection of blood, you should also consider whether you have experienced any of the following which might affect the test:

• You have undergone a digital rectal exam in the last two days leading up to blood collection.
• You have had a prostate biopsy in the last two weeks.
• You are suffering from constipation.

PSA blood levels

Normally, your PSA level would be below 4 ng/ml which is the internationally recognised dividing line between normal and raised PSA levels. The difficulty in diagnosing prostate cancer through the PSA test is that up to 20% of patients with cancer have a PSA level below 4 ng/ml and at the same time, far from every patient with a PSA level of 4-10 ng/ml has prostate cancer. Only 25% of patients in this diagnostic grey zone have prostate cancer.

The patient’s age plays an important role in the PSA testing. We know that with increasing age, the PSA level gradually increases so this age-specific PSA is nowadays usually considered when making a diagnosis. For men aged 40-49 years, an upper limit of PSA of 2.5 ng/ml has been proposed, 3.5 ng/ml for 50-59 years, 4.5 ng/ml for 60-69 years, and 6.5 ng/ml for 70 years and older.

[1] Although the possibility of elevated PSA levels after ejaculating, cycling, or digital prostate examination have not been confirmed in reputable studies, we recommend avoiding all of the above activities.

A prostate biopsy is an examination method that involves the removal of cells from the prostate tissue. It plays an especially important role in the diagnosis of prostate cancer. Without a biopsy and histological examination, it is not possible to diagnose prostate cancer. Doctor may suspect a prostate tumour based on digital rectal examination or based on an elevated PSA concentration, but only an analysis of the tissue can confirm or rule out any suspicion. For benign tumours, the biopsy and subsequent tissue analysis will provide information about the nature of the changes which will help in deciding on further treatment.

The biopsy is performed with a special biopsy needle using an ultrasound probe inserted into the rectum. During the examination, an ultrasound probe is first inserted into the rectum to help localize the sites from which tissue will be taken. The actual tissue collection is done from about 10 to 12 sites in the prostate. The examination is not painful but rather uncomfortable, you can ask your doctor for local anaesthesia. Biopsy usually takes 10 to 15 minutes.

Before the procedure, thorough emptying of the rectum is necessary (the patient should use glycerine suppositories) and in some cases, antibiotics are also administered. If you are taking blood-clotting medication, you need to consult your doctor and stop taking it 5 days before or replace it with some more appropriate medication.

Tissue samples are then sent for histological examination to rule out or confirm the presence of cancer cells.

Currently, there are three methods of prostate biopsy:

• Standard prostate biopsy, in which your doctor takes samples of prostate tissue through a special rectal ultrasound probe attachment.
• A perineal prostate biopsy, which uses a more advanced ultrasound probe connected to a stepper, a device for stabilizing the probe and precise manipulation. This type of biopsy is performed through the perineal area and is precisely targeted whilst presenting a lower risk of subsequent infection and bleeding.
• Fusion biopsy involves obtaining data from two different sources, magnetic resonance imaging (MRI) and ultrasound. First, we identify the suspicious lesion in the prostate through the MRI and then combine the image produced by the ultrasound. Linking these two images allows for more precise targeting of the pathological lesion and its safe removal. The fusion biopsy technology allows the lesion to be imaged on multiple levels. This increases the possibility of capturing even very small foci.  This type of biopsy is performed through the perineum, similarly to perineal prostate biopsy.

An ultrasound, or sonography, is non-invasive and painless. During the examination, the doctor will place the ultrasound probe on the part of the body being examined. The examination is performed lying on your back. Generally speaking, there are very few occasions where only an ultrasound would be sufficient enough for a diagnosis, additional examinations are almost always necessary.

Magnetic resonance imaging (MRI) provides a detailed view of individual anatomical regions of the human body. It contributes significantly to the diagnosis and clarification of health problems within specific areas, which can have a major impact on the further course of treatment. The examination is performed in a strong magnetic field and is painless. You may find the relatively loud noise slightly disturbing but this is nothing to worry about, the noise is caused by the movement of the individual components.

For prostate MRI, it is very often necessary to inject a contrast agent into the vein. The agent is used to enhance and improve the quality of the MRI images and highlight structures in the patient's body. If you are advised to take a contrast agent for an MRI scan, it is advisable not to eat, chew gum or smoke 4 hours prior to the scan. Drink small sips of up to 150 ml of still water.

First, you will lie down on the examination table and a radiological assistant will help you get into the correct position and place MRI coils on the viewed area. These coils are necessary and allow for the best imaging possible. Throughout the whole duration of the procedure, between 25-90 minutes, you will lie still and breathe regularly. Any movement will affect the images taken.

If you have a pacemaker, defibrillator or any other electronic medical device in your body, a cochlear implant or a splinter in your eye, you are unfortunately NOT allowed to undergo an MRI scan. Exception can be made only if you can provide a written confirmation from the implant manufacturer stating that the implant is fully MRI compatible as well as a written MR examination consent from the surgeon that performed the implantation.

Unfortunately, you also CANNOT undergo the examination if you have metal heart valves, joint replacements, metal clips from surgery, vena cava filters, clips from brain surgery, stents, vascular reinforcements, and other metals implanted in your body for less than 6 weeks. Again, an exception is only possible if you have written confirmation from the implant manufacturer that the implant is fully MR compatible, and you also have the written MR examination consent from the surgeon that performed the implantation. Last but not least, it is important that a period of at least 6 weeks has passed since your implantation. This is to allow the implant to properly "settle" in the body.

PET/CT is a nuclear medicine diagnostic imaging method used primarily for cancer diagnosis. The examination combines functional (metabolic) and anatomical (morphological) images within a single instrument. The examination requires intravenous administration of special radioactive substances called radiopharmaceuticals and sometimes also iodine contrast agents for more accurate imaging. During the procedure, you will be exposed to ionising radiation which you won’t feel in any way. Both the scanner and the radioactive substances (radiopharmaceutical) injected into the vein, are sources of the ionising radiation. The simultaneous performance of both of these methods and using them in combination (hybrid imaging) allows to determine the exact anatomical localization of the pathological finding, evident from the metabolic image. The result of the PET/CT examination contributes to correct diagnosis decisions, or clarification of a health problem, simultaneously it allows for optimization of a therapeutic or further diagnostic procedure.

This type of examination may be indicated based on the location of the tumour, localization of metastases, or when localizing a recurrence of prostate cancer.